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04100113i 0� zr G W� UC V. OF F• C G U`e CITY OF CUPERTINO CONTRACTOR IN q BUILDING DIVISION PERMIT RUILDINGADDRESS: RESPONSIBLE ROOFING INC' PERMIT N04100113 0385 STERN AVE OWNER'S NAME: PERMIT ISSUE DATE LOU SACHWITZ 2882 SPRING ST -...10/15/2004 ONE: SANITARY N0, CONTROL NO. (650)969-6151 ARCHITECTIENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 i LICENSED CONTRACTOR 'SDECLARATION ' Job Description I hereby affrm that 1 am liccnud under pmviaions of Chapter 9 (tro mencing i with Socamilmimf Division Sof NC Buhincsx and Professions Codc, antlmyliecnseis reeamaefr t. ;Z8 NA eJ1 GRAVEL pLicense Class Leen Lic.p �Qec. Dam Conl(aelof Q ARCHITECTS DECLARATI NNS I understand my plans shall he used es public (crams t Nnv 2004 Licensed Professional I OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law Tor dee fallowing reason. (Second 703 1.5, Business and Prafessinns Cade Any city or count which requires a pc.it m cnn unwL site,, tmpmve, demolish, ar repair any strum wdsmmme $7700 prions its issuance, also requires the applicant for such permilla lite as. Lw ie3 Valuation that he is licensed personal the provisions of the Contractor's License (Chapter g (commencing wi th Section 7000) of Division 3 of the B ustne5s and Professions Code)or Fail he is exempt deuterium and me basis for the alleged exemption. Any violation of 3 AIIIQ RtnfibeO 0 Occupancy Type Section 7031.5 by any applicant fora Permit subjects the applicant 10 a civil penalty of not more man Ran hundred dmlara (5500). ❑ Lotownerof the property,or empleycu with wages Nei(sole Required Inspections' 0014. Business GUI.B Business will do me work, and the for is net intended or r I, arms not a(Sec. and Professional cooe: The Contractor's License Law docs he Con Law apply to an owner or or progeny who builds and who work himself ugh his that sumcrcom are ed for own employees, provided that such improvements are net intended or offered for owner. meaveteorimprovementissold within one year or completion,theowner- inori bbuilder Twill have me burden of proving that he did not build or improve for purpose of ilder, saleI sale.). ❑ I, as owner of me property, am exclusively contracting was licensed camme, rs to consuperthe project (Sec.J014. Business and Professions Codef, The Contractor's Li. cense Law does not apply to an owner of property who builds or improves Reason, and who contracts for such projects with a contraction(s) licensed pursuant to the Contractor's License Law. ❑ I an exempt under Sce. ,B III P C for this reason Owner Dam WORKER'S COMPENSATION DECLARATION I hereby affrm under penalty of perjury ane of the following declarations: - ❑ I have and will maintain a Cenificate of 0mourl to self-inaute fur Worker's Compen- sation, as provided for by Section 3100 of the Labor Code. for the performance of the work far which this permit i5 issued. ❑ I haw and will maintain Worker's Compensation Insurance, ex modified by Section 31W of the Labor Code, for the performance or are work for which this permit is issued. My Workers Cam pensation insurance carrier and Policy number am: /I020try ./` S6 Cartier..�� CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not becomplened if the permit is for one hundred didurs (SI00) ar less.) 1 hearty that in the performance of the work for which this permit is issuctl, l shall not employ any person in any manner u az w become subject o thh Workers' Compensation Laws of California. Date Applicant .. NOTICE TO APPLICANT. If. after making this Cer ilicam of Exemption, you should become subject we the Workers Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall Fc deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that mere is construction lending agency for the performance of the work fur which this permit is issued(See3097, ON. C.) , Under's Name Lcndcr'Address 1 this is application and sum that the above information is 4 I ccnee mcomply correct, l agree m comply with all city and county ordinances and state laws relating to with C huildingeonsuuctioo and bar amhorim,eprcsematives of this city m arae, upon me perty re ihaVC-(We)agre lmSpify pkeep an to ha (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities judgments, costs and expenses which may in any way aceme against said City s in consequence or the granting of permit. / ^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by: Date SOURC�R��FrGULATIyO 5. ;4K/ � /O - ` Re -roofs Signature of ApplicanUComranor Data HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will me applicant or future building occupant store or handle harardous material - ex defined by the Cupertino Municipal Code, Chapter 9.12, and the HeaRh and Safety Code , secaon 25532(a)1 All roofs shall be inspected prior to an roofing material beim installed. P P Y g ❑Ye, 2fe g If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or future building occupant use equipment or devices which emit hazardonv air contaminants ss defined by the Bay Arca Air Quality Management all new materials for inspection. District? I / ❑Yes mo I have mad the hurnmous mannalsrequiremenm under Chapterii 95 of the Cantor- , 0 55 d maccup huiWirg utasnotca lifft tot yhavratcnant. 2myr snd255ility ✓/�/ �D E �� dt oat eut(andy M1ave ¢nem, that antl is mdinfly me 25th, (eepon5534,y to nodfy dee y L% _P rcyuircmcn whientnat rtrtisaaancemrachninemeonxcur.,. Signature of Applicant Date 16'-z I- All roof coverings to be Class "B" or better Owner or aumorixed igem Date It �. CITY OF UPEkTINO Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax (408) 777-3333 Building Department JOB ADDRESS: PERMIT # 103&S 5-4erh Ave. 6 1110e117 OWNER'SNAME: Lou PHONE #Koax)5jon-Sq GENERAL CONTRACTOR: FAX # t(oSG) C6 -SSI e I am not using any subcontractors: Signature Date Please check ant)licable subrnnf-rarinrq and rmmnlPfP i-hP fnllnWinu in Fnnvotirn• Owner/Contract Signature iU 0 Date SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring: Carpeting Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting / Wallpaper Paving Plastering Plumbing ✓ Roofing 122S 3� 8�}qp Septic Tank Sheet Metal Sheet Rock Tile Owner/Contract Signature iU 0 Date CITY OF UPEkTINO Community Development Department Building Division City of Cupertino 10300 Torre Avenue Telephone: (408) 777-3228 Fax: (408) 777-3333 Building Department Subject: Re -roofing policy for the City of Cupertino 1. Prior to permit issuance, you must agree to comply with 1997 UBC Standards and manufacturers specifications on re -roofing. 2. New roof coverings shall not be applied without first obtaining all inspection and written approval from the building inspector. A final inspection and approval shall be obtained from the building inspector when the re -roofing is completed. 3. All roofs shall be inspected prior to any roofing installation. 4. To receive a final sign off from the City, the following steps are required: 1) Pre -inspection and/or tear off approval. 2) In -progress inspection approval. 3) Final inspection approval. a) Spark arrester installation. 5. If plywood is installed, a plywood nail inspection is required. 6. Any roofing which is applied without first obtaining an inspection, will require the removal of all new material down to the sheathing, so a proper City inspection can be performed. IMPORTANT: 1. Flat roofs must have a minimum of 1/4 " per foot slope and demonstrate that there is no ponding. 2. An I.C.B.O. report is required to be on the job site at the time on inspection. I understand and will comply with the above stated policy on re -roofing. Homeowner's Name: LO() 'SCA(-V) i n t i Job Site Address: 103b5 51tr n A1FP Roofing Company Name: �t sp1/ns i Hx g(1„ Ute, Sr C . A plicant's Signature: ( Date: 10 p4- Greg eel Building Official Revised 1/30/03 Printed an Recycled Paper Cm o CUPERTINO CITY OF CUPERTINO REROOF PERMIT APPLICATION FORM AUNT '# � Date: '15 - G - G Energy 10 1b4 Building Address: Seismic Fee Res 10-5a5 k4 Owner's Name: BUILDING Phone #: LoLj S CAChW i % C-qo ) 3C1 - U4 Contractor: Phone #: License #: 41T Contact: Phone #: Cupertino Business License #: e, ((P 1 8-Sgej) Type of Roof Covering: Existing: Proposed: t"Built-Up Roof ai -Built-Up roof ❑ Asphalt Shingles ❑ Asphalt Shingles ❑ Wood Shakes ❑ Wood Shakes ❑- Wood Shingles - ❑ Wood Shingles ❑ Other (Specify) ❑ Other (Specify) Number of existing coverings I ❑ Provide I.C.B.O. Report # M9 -To be Removed ❑ Provide Mfgr. Installation Specs. I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy: Job Description: T2G tr�W. � V vqyOvel v6 Residents 1 Ep- Commercial ❑ Fire Zone: Yes ❑ No ❑ Confirmed with Planning Dept. if there are any restrictions: LJ Cost of Project: Type of Construction: Occupancy group: f- co":6 1�-e--ro 5 9- - Qty. if Aonli,ra lad Fee ID Fee Descrintion Fee C;rnun BPERMFEE Bldg Permit Fees BUILDING BENERGY Energy BUILDING BSEISMICRE Seismic Fee Res BUILDING BSEISMICOM Seismic Commercial BUILDING BPLANCHK Plan Check Fee BUILDING BUSLIC Business License BUILDING 41 z 7 K -S" 3 of -6